Lisa B Kenney1, Bethany Ames2, Alexis L Michaud3, David N Williams4, Peter E Manley1, Nicole J Ullrich5. 1. Dana-Farber Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts. 2. Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire. 3. Dana-Farber Cancer Institute, Boston, Massachusetts. 4. Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts. 5. Department of Neurology, Boston Children's Hospital, Dana-Farber Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts.
Abstract
BACKGROUND: Evidence is not available to guide management of childhood cancer survivors (CCS) at risk for radiation-associated cerebral vascular disease (CVD) and stroke. We propose to use a consensus-based methodology to describe the collective opinion of regional experts for the care of these patients and identify areas of controversy. PROCEDURE: Thirty physicians from the New England region who care for CCS participated in a Delphi panel querying their management approach (imaging, laboratory tests, medications, counseling, referrals) to a CCS treated with cranial radiation formatted as five clinical scenarios (asymptomatic, small- and large-vessel CVD, transient ischemia, stroke) in three rounds of anonymous questionnaires. Consensus defined as ≥90% agreement. RESULTS: Response rate was 100% for all three rounds. Panelists reached consensus on laboratory tests to assess stroke risk factors, stroke risk and prevention counseling, brain imaging to monitor survivors with known CVD, and acute care for stroke symptoms. Only 67% panelists agreed with MRI screening asymptomatic survivors with no history of CVD, 87% endorsed aspirin as stroke prevention for large-vessel CVD and 57% for small-vessel CVD. There was no consensus on specialty referrals. Overall, panelists practicing at large institutions and neurology subspecialists were more likely to advocate for screening, interventions, and referrals. CONCLUSIONS: Despite lack of evidence to guide stroke prevention in CCS treated with cranial radiation, a panel of regional physicians reached consensus on managing most clinical scenarios. Controversial areas requiring further study are surveillance imaging for asymptomatic survivors, aspirin for stroke prevention, and indications for specialty referral.
BACKGROUND: Evidence is not available to guide management of childhood cancer survivors (CCS) at risk for radiation-associated cerebral vascular disease (CVD) and stroke. We propose to use a consensus-based methodology to describe the collective opinion of regional experts for the care of these patients and identify areas of controversy. PROCEDURE: Thirty physicians from the New England region who care for CCS participated in a Delphi panel querying their management approach (imaging, laboratory tests, medications, counseling, referrals) to a CCS treated with cranial radiation formatted as five clinical scenarios (asymptomatic, small- and large-vessel CVD, transient ischemia, stroke) in three rounds of anonymous questionnaires. Consensus defined as ≥90% agreement. RESULTS: Response rate was 100% for all three rounds. Panelists reached consensus on laboratory tests to assess stroke risk factors, stroke risk and prevention counseling, brain imaging to monitor survivors with known CVD, and acute care for stroke symptoms. Only 67% panelists agreed with MRI screening asymptomatic survivors with no history of CVD, 87% endorsed aspirin as stroke prevention for large-vessel CVD and 57% for small-vessel CVD. There was no consensus on specialty referrals. Overall, panelists practicing at large institutions and neurology subspecialists were more likely to advocate for screening, interventions, and referrals. CONCLUSIONS: Despite lack of evidence to guide stroke prevention in CCS treated with cranial radiation, a panel of regional physicians reached consensus on managing most clinical scenarios. Controversial areas requiring further study are surveillance imaging for asymptomatic survivors, aspirin for stroke prevention, and indications for specialty referral.
Authors: John T Lucas; Austin M Faught; Chih Yang Hsu; Lydia J Wilson; Yian Guo; Yimei Li; Raja Khan; Jared B Becksfort; David A LeVine; Yousef Ismael; Kaleb Darrow; Vadim P Moskvin; Fakhriddin Pirlepesov; Paul Klimo; Lucas Elijovich; Daniel J Indelicato; Fredrick A Boop; Thomas E Merchant Journal: Int J Radiat Oncol Biol Phys Date: 2022-01-03 Impact factor: 8.013
Authors: Sungmin Woo; Abdallah Araji; Mohammad Ali El Amine; Natalie Gangai; Elizabeth Acquafredda; Anita P Price; Tanya M Trippett; Hedvig Hricak; Hebert Alberto Vargas; Gerald G Behr Journal: Cancer Imaging Date: 2021-08-28 Impact factor: 3.909